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Coercive Control and Intimidation

Acts perceived by recipients as violent or threatening

Recipient's fear of attack or retliation

Threat alternated with kindness

Notes:

Coercive control and intimidation by the
abusive partner is considered an underlying component of all of
these types of violence. Acts are considered to be violent if they are
perceived by the recipient as violent or threatening. Much of the abusive
partner’s ability to control relies on the abused person’s belief that
if she does not comply, either she, her children, or other persons or
things she cares about will come under attack.

Often, threats are alternated with acts of
kindness from the perpetrator, making it all the more difficult for the
victim to break free of the cycle of violence.

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Violence and Pregnancy

At least 4–8% of women report violence during pregnancy

As many ass 324,00 women who gave birth in 1998 experienced violence

Notes:

Now that we have defined intimate partner
violence, what about its link to pregnancy?

In a CDC review, researchers found that
depending on the population, setting, or frequency of asking, between 0.9
and 20.1% of women reported experiencing violence during pregnancy. In 8
of 11 of these studies, 4–8% of women reported experiencing violence
during pregnancy.3

Using this conservative range of
prevalence, of the 4 million women who delivered live-born infants in
1998, between 152,000 and 324,000 would have experienced violence during
pregnancy. This number is similar to estimates in previous years and does
not include the number of women who had pregnancies that did not result in
a live birth.

Researchers have not yet been able to
determine definitively whether violence actually begins, ends, or
increases during pregnancy. They also have not been able to determine if
it continues throughout pregnancy or begins in the postpartum period. More
research is needed to replicate the studies that have explored each of
these time frames.

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Violence and Pregnancy

Violence during pregnancy may be more common than:

Gestational diabetes

Neural tube defects

Preclampsia

Notes:

We know that violence during pregnancy may be
more common than some conditions for which most pregnant women are
routinely screened.3 As with screening for gestational
diabetes, neural tube defects, preeclampsia, and behavioral risk factors
such as smoking and alcohol use, screening for intimate partner violence
should be incorporated into routine prenatal care.

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Possible Demographic and Psychosocial Factors

Young maternal age/adolescence

Unintended pregnancy

Delayed prenatal care

Smoking

Alcohol and drug use

Lack of social supports

STD/HIV/AIDS

Notes:

Women who report violence around the time of
pregnancy also have reported higher prevalence of some demographic and
psychosocial risk factors that also may have an effect on pregnancy. These
include:

(Read slide text)

Although there is no single profile of an
abused woman, it should be noted that adolescents are at increased risk
for violence—from either their partner or from a family member. Women
with HIV or AIDS are also at increased risk for violence.

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Possible Effects on Fetus

Direct effects

spontaneous abortion

fetal injury or death from maternal trauma

Indirect effects

maternal stress

materanl smoking

alcohol or drug use or abuse

Notes:

No consistent research findings indicate
whether fetal health is affected by violence.9 Severe cases of
physical abuse are known to have direct effects on the fetus. An example
would be fetal injury or death associated with trauma to the mother.

In addition, fetal health could be affected
indirectly through maternal stress, smoking, or alcohol or drug use or
abuse—all of which might be responses to the violence itself. These
conditions and behaviors are known to be associated with poor outcomes
such as low birth weight, intrauterine growth restriction, and fetal
alcohol syndrome.

Moreover, women in abusive relationships
may find it difficult or impossible to fulfill prenatal care
recommendations such as frequency of visits, prescribed supplements,
nutrition, STD prevention, or substance-abuse recovery programs.

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Possible Risks for Children

Violence may involve other household members

Witnessing violence is a risk factor for abusive relationships as an
adult

Intimate partner violence often is associated
with abuse of other household members, particularly children. Research
indicates that violence is a learned behavior, and witnessing violence in
the home as a child is a strong risk factor for involvement in abusive
relationships as an adult.10

In addition, experiencing abuse as a child
has been associated with other risk factors such as depression, substance
abuse, poor school performance, and high-risk sexual activity.11,12

Clinicians have an opportunity not only to
identify and intervene on behalf of the abused woman, but also to assist
in breaking the intergenerational cycle that could affect her children.
Whenever possible, at the point of detection, clinicians should
communicate with the family’s other health care providers, such as
pediatricians. Clinicians should also be aware of and follow state
reporting requirements related to domestic violence or child abuse and
neglect.

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Barriers to Screening

Time constraints

Discomfort with the topic

Fear of offending the patient or partner

Perceived powerlessness to change the problem

Notes:

Although pregnancy offers an important
opportunity to screen for violence, most women report that they are not
asked about violence during pregnancy.13

When providers are asked why they do not
screen for violence, they commonly indicate four major barriers.14

(Read slide text)

Provider training in the use of efficient
assessment methods can help overcome these barriers. The following
information can help health care organizations and individual providers
increase competency in and commitment to screening for violence.

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Use Your "RADAR"

Routinely screen every patient

Ask directly, kindly, nonjudgementallly

Document your findings

Assess the patient's safety

Review options and provide referrals

Notes:

Steps in screening and intervention can be
summarized in the acronym RADAR, which was developed by the
Massachusetts Medical Society.15

The first step in the RADAR process is to routinely
screen for violence. Assume that all patients are at risk for violence
and ask every patient as part of her routine health assessment. Screening
requires that the provider ask directly for information at multiple
visits throughout the pregnancy.

In cases where violence is identified, document
your findings in the patient’s chart. Assess your patient’s
safety—is she or are her children in immediate danger? Finally, review
the patient’s options and provide her with referrals.

The next slides will take you through each
of these steps in greater detail.

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Routinely Screen Every Patient

At first prenatal visit

At least once per trimester

At postpartum checkup

At routine ob-gyn visits and preconception visits

Notes:

Screening should occur at various times over
the course of the pregnancy because some women do not disclose abuse the
first time they are asked and abuse may begin later in pregnancy. 12,16

Screening should occur at the first
prenatal visit, at least once per trimester, and at the postpartum
checkup.

For women who are not pregnant, screening
should occur at routine ob-gyn visits, family planning visits, and at
preconception visits.

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Components of Screening

Review medical history

Observe and record presentations and behaviors of patient and partner

Ask direct questions and listen actively

Document patient's response

Notes:

Screening for violence has a number of
components. First, review the woman’s medical history. Observe
presentations and behaviors of the patient and her partner. Ask direct
questions to assess her risk for violence and listen actively. Always
document the patient’s response, even when it is “no.”

PRAMS
A surveillance project of CDC and state health departments. PRAMS collects state-specific,
population-based data on maternal attitudes and experiences prior to, during
and immediately following pregnancy.